Program

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Program 1 of 2 Scroll down to see them all.

This program provides brand name medications at no or low cost.
Pharmaceutical Company	TEVA Pharmaceuticals
Program Name	Copaxone Patient Assistance Program
Program Address	Shared Solutions 901 East 104th St., Suite 900 Kansas City, MO 64131
Phone Number	800-887-8100
Fax Number	Not Applicable
Medications on Program	Copaxone Prefilled Syringe 20mg (glatiramer)
Application Forms	Not Applicable
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	The patient must be uninsured or underinsured and meet income guidelines that are not disclosed. Medical diagnosis necessary for this program is not specified. The patient must also be a US resident or legal alien. There are two programs: one for people with no insurance or who are underinsured (which is run by NORD) and one for people who need assistance with the co-payments through a chronic disease fund. This program is dependent on funding. If there is no funding available, then the patient is put on a list and contacted once funding is available to assist.
Application Process	Anyone can call to request an enrollment kit to be sent out. The enrollment form is faxed out. The completed enrollment form must be mailed back.
Application Requirements	The doctor must fill out and sign the enrollment form. The patient must fill out a section of the enrollment form and sign it.
Program Details	The medication is sent to the patient's home. The patient or doctor must contact the company for refills. Once a year a new application with financial documentation is needed.
Last Updated	October 09, 2009

Program 2 of 2.

This program provides help in applying for assistance with the cost of this drug.
Pharmaceutical Company	Diplomat Specialty Pharmacy
Program Name	Diplomat's Co-Pay Assistance Navigator Program
Program Address	Attn: Funding Department 2029 S. Elms Rd., Suite D, Swartz Creek, MI 48473
Phone Number	877-977-9118 ext. 10184
Fax Number	866-418-2650
Medications on Program	Copaxone Prefilled Syring 20mg (glatiramer)
Application Forms	Not Applicable
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	Individual eligibility and level of financial support is determined on a case by case basis. Medical diagnosis necessary for this program is not specified. US residency requirements are not specified. The Co-Pay Navigator is a full service program to help patients seek funding assistance for the co-pay portion of their required medications. There is no charge for this service. Physicians/physicians' offices may submit an application online at the website indicated above, or fax information as directed below.
Application Process	The physician/physician's office should fax the prescription, diagnosis, patient demographics and any insurance information to 866-418-2650 Attn: Sandy/Funding. A Patient Care Coordinator will contact the patient within 24-48 business hours.
Application Requirements	Will be discussed with the patient and physician after the initial request to the program is received.
Program Details	Not applicable.
Last Updated	August 05, 2009